Return by a Shareholder Making Certain Late Elections To End  
Form 8621-A                                                                                                                          OMB No. 1545-1950 
                               Treatment as a Passive Foreign Investment Company 
(December 2013)             ▶ Information about Form 8621-A and its separate instructions is at www.irs.gov/form8621a.                    Attachment   
Department of the Treasury    ▶ File Form 8621-A separately from your income tax return. See separate instructions.                       Sequence No. 69A
Internal Revenue Service 
Name of shareholder                                                                          Identifying number (see instructions) 

Number, street, and room or suite no. (If a P.O. box, see instructions.)                     Check type of shareholder filing the return: 
                                                                                             Individual         Corporation                Partnership 
City or town, state, and ZIP code or country                                                 S Corporation      Nongrantor Trust           Estate 

Name of shareholder contact (see instructions)                                               Telephone number of shareholder contact 

Name of former passive foreign investment company (PFIC) or Section 1297(e) PFIC             Employer identification number (if any) 

Address (Enter number, street, city or town, and country.) 

Part I   Elections (see instructions) 
A       Late Deemed Dividend Election With Respect to a Former PFIC.                         I, a shareholder of a Former PFIC, within the meaning of
        Regulations section 1.1291-9(j)(2)(iv), elect to make a late deemed dividend election with respect to the Former PFIC. My 
        holding period in the stock of the Former PFIC includes the termination date, as defined in Regulations section 1.1298-3(d). I 
        am requesting consent to make this election before a representative of the Internal Revenue Service has raised upon audit 
        the PFIC status of the Former PFIC for any of its taxable years. Complete Part II, lines 1, 2, and 3, and Part IV. 
B       Late Deemed Sale Election With Respect to a Former PFIC.                             I, a shareholder of a Former PFIC, within the meaning of 
        Regulations section 1.1291-9(j)(2)(iv), elect to make a late deemed sale election with respect to the Former PFIC. My holding 
        period in the stock of the Former PFIC includes the termination date, as defined in Regulations section 1.1298-3(d). I am 
        requesting consent to make this election before a representative of the Internal Revenue Service has raised upon audit the 
        PFIC status of the Former PFIC for any of its taxable years. Complete Part II, lines 1, 2, and 4, and Part IV. 
C       Late Deemed Dividend Election With Respect to a Section 1297(e) PFIC. I, a shareholder of a Section 1297(e) PFIC, within 
        the meaning of Regulations section 1.1291-9(j)(2)(v), elect to make a late deemed dividend election with respect                           to the Section 
        1297(e) PFIC. My holding period in the stock of the Section 1297(e) PFIC includes the CFC qualification date,  as                          defined in 
        Regulations section 1.1297-3(d). I am requesting consent to make this election before a                 representative of the Internal Revenue 
        Service has raised upon audit the PFIC status of the Section1297(e) PFIC for any of its taxable years. Complete Part III, lines 5, 
        6, and 7, and Part IV. 

D       Late Deemed Sale Election With Respect to a Section 1297(e) PFIC. I, a shareholder of a Section 1297(e) PFIC, within the
        meaning  of  Regulations  section  1.1291-9(j)(2)(v),  elect  to  make  a  late  deemed  sale  election  with  respect  to  the  Section
        1297(e) PFIC. My holding period in the stock of the Section 1297(e) PFIC includes the CFC qualification date, as defined in
        Regulations  section  1.1297-3(d).  I  am  requesting  consent  to  make  this  election  before  a                        representative  of  the  Internal
        Revenue Service has raised upon audit the PFIC status of the Section 1297(e) PFIC for any of its taxable years. Complete 
        Part III, lines 5, 6, and 8, and Part IV. 

Part II  Information for Elections With Respect to Former PFICs 
1    The termination date, as defined in Regulations section 1.1298-3(d), for the Former PFIC is                                                       ,      . 
2    The taxable year of the shareholder in which the termination date falls is the taxable year beginning                                               , 
     and ending                                            ,              (“election year”). 
3    The shareholder’s pro rata share of the post-1986 earnings and profits of the Former PFIC that is treated as distributed to the 
     shareholder on the termination date is                               $       . Attach a  schedule  that shows the  calculation  of  this  amount 
     as required under Regulations section 1.1298-3(c)(5)(ii). In addition, if the shareholder filed a Form 5471 for the Former PFIC for 
     the election year, attach Schedule J (Form 5471). 
4    The amount of gain the shareholder elects to recognize on the deemed sale of the shareholder’s  interest in the  Former PFIC is
     $                         . Complete the balance sheet on page 4 for the Former PFIC for the election year. 
Part III Information for Elections With Respect to Section 1297(e) PFICs 
5    The  CFC  qualification  date,  as  defined  in  Regulations  section  1.1297-3(d),  for  the  Section  1297(e)  PFIC 
     is                                        ,             . 
6    The  taxable  year  of  the  shareholder  in  which  the  CFC  qualification  date  falls  is  the  taxable  year  beginning 
                               ,                  and ending                                  ,                  (“election year”). 
7    The shareholder’s pro rata share of the post-1986 earnings and profits of the Section 1297(e) PFIC that is treated as distributed
     to the shareholder on the CFC qualification date is                 $                     . Attach a schedule that shows the calculation of this
     amount as required under Regulations section 1.1297-3(c)(5)(ii). In addition, if the shareholder filed a Form 5471 for the Section 
     1297(e) PFIC for the election year, attach Schedule J (Form 5471). 
8    The amount of gain the shareholder elects to recognize on the deemed sale of the shareholder’s interest in the Section 1297(e) 
     PFIC  is  $                                . Complete the balance sheet on page 4 for the Section 1297(e) PFIC for the election year. 
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                          Cat. No. 39480Y              Form  8621-A (12-2013) 

Form 8621-A (12-2013)                                                                                                                Page 2 
Part IV    Computation of Tax and Interest Due 
9a   Excess distribution. Enter amount from line 3 or 4 of Part II or line 7 or 8 of Part III  . . . .             9a 
b    Attach a statement that   (a)    shows the shareholder’s holding period for each share of stock or 
     block of shares held, (b) allocates the amount on line 9a to each day in the shareholder’s holding 
     period, and (c) aggregates all amounts that are allocated to the same taxable year.
10   Enter the total of the amounts determined in line 9b that are allocable to the election year and to 
     taxable years before the foreign corporation became a PFIC (pre-PFIC years)  .  .    .      . . .             10 
11   Enter the shareholder’s income tax liability for the election year if the amount on line 10 above 
     had been included in gross income for such year .     . .       . . . . . . . . .    .      . . .             11 
12   Enter the amount of the shareholder’s income tax liability (see instructions), as reported on its 
     original or amended income tax return for the election year.  .     . . . . . . .    .      . . .             12 
13   Subtract line 12 from line 11        . . . .    . . . . .       . . . . . . . . .    .      . . .             13 
14   Enter the aggregate increases in tax (before credits) for each taxable year in the shareholder’s 
     holding period (other than the election year and pre-PFIC years) .    . . . . . .    .      . . .             14 
15   Foreign tax credit (see instructions)  .   .    . . . . .       . . . . . . . . .    .      . . .             15 
16   Subtract line 15 from line 14        . . . .    . . . . .       . . . . . . . . .    .      . . .             16 
17   Determine  interest  on  each  net  increase  in  tax  determined  on  line  16  above  in  the  manner 
     described in the instructions. Enter the aggregate amount of interest here  . . .    .      . . .             17 
18   Add lines 13, 16, and 17  .      .   . . . .    . . . . .       . . . . . . . . .    .      . . .             18 
19   Determine interest on the line 18 amount in the manner described in these instructions. Enter the 
     aggregate amount of interest here. See instructions  .  .       . . . . . . . . .    .      . . .             19 
20   If the shareholder received an excess distribution in a prior taxable year that was not reported on a 
     Form 8621, the shareholder must determine the additional tax and interest due under section 1291 as a 
     result of such excess distribution (including the interest from the due date of the return for the taxable 
     year in which the excess distribution was received until the date this form is filed with the IRS). Attach  a 
     completed Form 8621 showing the computation of the amount and enter the amount here  .      . . .             20 
21   Balance due. Add lines 18 through 20  .         . . . . .       . . . . . . . . .    .      . . .             21 
Important: Attach to Form 8621-A a copy of the Form 8621 filed by the shareholder for any taxable year in which the shareholder received
an excess distribution from the foreign corporation. 

           Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
           and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 
Sign  
Here 
           © Signature and Title (if any)                                          © Date 
           Print/Type preparer’s name           Preparer's signature             Date
Paid                                                                                                 Check           if PTIN
                                                                                                     self-employed
Preparer                   ▶                                                                       Firm's EIN  ▶
           Firm’s name     
           Firm's address  
Use Only                   ▶                                                                       Phone no.
                                                                                                                        Form  8621-A (12-2013) 

Form 8621-A (12-2013)                                                                                                                 Page 3 
                         Closing Agreement on Final Determination Covering Specific Matters   
                                           ▶  File this Closing Agreement in Duplicate (see instructions). 
Name of shareholder                                                          Identifying number (see instructions) 

Name of passive foreign investment company                                   EIN or identifying number (see instructions) 

Under section 7121 of the Internal Revenue Code of 1986, as amended (“the Code”), the shareholder filing this Form 8621-A (“Shareholder”), 
and the Commissioner of Internal Revenue (“Commissioner”) hereby make the following closing agreement (“Closing Agreement”). 
WHEREAS, Shareholder is requesting consent to make the election specified in Part I of this Form 8621-A with respect to the  PFIC 
specified on page 1 of this Form 8621-A (“Corporation”). 
WHEREAS, Shareholder has completed ALL of the applicable information requested on pages 1 and 2 of this Form 8621-A, which 
is incorporated into this closing agreement by reference. 
WHEREAS, under Regulations section 1.1298-3(e)(1) and Regulations section 1.1297-3(e)(1), the  Commissioner may grant consent 
to  make     a      late purging election     if (1)   Shareholder           requests  consent  to         make    such   election    before 
a representative of the Internal Revenue Service raises upon audit the PFIC status of the foreign corporation for any taxable year 
of Shareholder; (2) Shareholder has agreed in a closing agreement with the Commissioner to eliminate any prejudice to the interests 
of the U.S. Government as a consequence of Shareholder’s inability to file amended returns for the taxable year in which the CFC 
qualification date or termination date, as applicable, falls, or an earlier closed taxable year in which Shareholder has taken a position 
that is inconsistent with the treatment of the Corporation as a PFIC; and (3) Shareholder satisfies the procedural requirements set 
forth in Regulations section 1.1298-3(e)(3) or Regulations section 1.1297-3(e)(3). 
WHEREAS,  Regulations  section  1.1298-3(e)(2)  and  Regulations  section  1.1297-3(e)(2)  provide  that  the    interests  of  the  U.S. 
Government  are  prejudiced  if  granting  relief  would  result  in  Shareholder  having  a  lower  tax  liability  (other  than 
by  a  de  minimis  amount),  taking  into  account  applicable  interest  charges,  for  the  taxable  year  that  includes  the  CFC  qualification 
date or termination date, as applicable (or a prior taxable year in which Shareholder took a position on a return that was inconsistent 
with  the  treatment  of  the  Corporation  as  a  PFIC),  than  Shareholder  would  have  had  if  Shareholder  had  properly  made  the  section 
1298(b)(1) election in the time prescribed in Regulations sections 1.1298-3(b)(3) or (c)(4) or Regulations sections  1.1297-3(b)(3) or (c)(4) or 
had not taken a position in a return for an earlier year that was inconsistent with the status of the Corporation as a PFIC. 
THEREFORE, based on the material submitted by Shareholder in connection with this Closing Agreement, and in the absence of 
other material factual or legal circumstances concerning the events described above, it is determined and agreed for federal income 
tax purposes that— 
1. The Commissioner grants Shareholder permission to make the election specified in Part I of this Form 8621-A with respect to 
Corporation. 
2. If Shareholder had made a timely election for the Election Year for Corporation, it would have had an increase in tax for the 
Election Year in the amounts shown in Part IV of this Form 8621-A. Therefore, the payment of the amount shown on line 21 of this 
Form 8621-A is sufficient to eliminate any prejudice to the interest of the U.S. Government as a result of Taxpayer’s inability to file 
a return for the Election Year, a closed taxable year. 
3. Shareholder’s basis in the stock of Corporation owned directly by the shareholder will be increased by the amount of the gain 
resulting from the deemed sale  election shown on line 4 or line 8 of this Form 8621-A or the amount of the deemed dividend resulting 
from the deemed dividend election shown on line 3 or line 7 of this Form 8621-A. 
4. This Closing Agreement constitutes a resolution under the Code of the specific matters discussed herein. No inference shall 
be made with respect to whether this resolution satisfies other federal law. 
5. Shareholder understands that Shareholder may have defenses to the collection of tax described in the preceding paragraphs. 
Nevertheless, Shareholder voluntarily waives all defenses to the assessment and collection of tax, penalties, and interest described 
in the preceding paragraphs, including any defenses based on the expiration of the period of limitations on assessment or collection. 
NOW  THIS  CLOSING  AGREEMENT  WITNESSETH,  that  Shareholder  and  the  Commissioner  hereby  mutually  agree  to  the 
determinations  set  forth  above  and  further  mutually  agree  that  those  determinations  shall  be  final  and  conclusive,  subject, 
however,  to  reopening  in  the  event  of  fraud,  malfeasance,  or  misrepresentation  of  material  fact,  and  provided  that  any 
change  or  modification  of  applicable  statutes  or  tax  conventions  shall  render  this  Closing  Agreement  ineffective  to  the  extent 
that it is dependent upon such statutes or tax conventions. 
IN WITNESS WHEREOF, by signing the foregoing, the above parties signify that they have read and agreed to the terms of this 
document. 

By:                                                         Date: 

Title: 

COMMISSIONER OF INTERNAL REVENUE 

By:                                                         Date: 

Title: 
                                                                                                                          Form 8621-A (12-2013) 

Form 8621-A (12-2013)                                                                                                Page 4 
                                                Balance Sheet for Election Year 
Complete this balance sheet if the shareholder is making election B or D. 
Important: Report  all  amounts  in  U.S.  dollars  prepared  and  translated  in  accordance  with  U.S.  GAAP.  See  the 
instructions for an exception for DASTM corporations. 
                                                                                    (a)                       (b) 
                                   Assets                                           Beginning of annual       End of annual  
                                                                                    accounting period    accounting period 
1   Cash  . .         . . . . . .  .  .    . .    . . .   . . .    . . . . .    1 
2a  Trade notes and accounts receivable .    .    . . .   . . .    . . . . .    2a 
b   Less allowance for bad debts  .   .    . .    . . .   . . .    . . . . .    2b  (                                ) (                                )
3   Inventories  .      . . . . .  .  .    . .    . . .   . . .    . . . . .    3 
4   Other current assets (attach schedule)  .     . . .   . . .    . . . . .    4 
5   Loans to shareholders and other related persons .     . . .    . . . . .    5 
6   Investment in subsidiaries (attach schedule)    . .   . . .    . . . . .    6 
7   Other investments (attach schedule)  .   .    . . .   . . .    . . . . .    7 
8 a Buildings and other depreciable assets  .     . . .   . . .    . . . . .    8a 
b   Less accumulated depreciation     .    . .    . . .   . . .    . . . . .    8b  (                                ) (                                )
9 a Depletable assets  .    . . .  .  .    . .    . . .   . . .    . . . . .    9a 
b   Less accumulated depletion     .  .    . .    . . .   . . .    . . . . .    9b  (                                ) (                                )
10  Land (net of any amortization)  . .    . .    . . .   . . .    . . . . .    10 
11  Intangible assets (see instructions for required attachments): 
a   Goodwill  .       . . . . . .  .  .    . .    . . .   . . .    . . . . .    11a 
b   Organization costs  .   . . .  .  .    . .    . . .   . . .    . . . . .    11b 
c   Patents, trademarks, and other intangible assets  .   . . .    . . . . .    11c 
d   Less accumulated amortization for lines 11a, b, and c  .  .    . . . . .    11d (                                ) (                                )
12  Other assets (attach schedule)  . .    . .    . . .   . . .    . . . . .    12 

13  Total assets  .     . . . . .  .  .    . .    . . .   . . .    . . . . .    13 
                      Liabilities and Shareholders’ Equity 
14  Accounts payable  .     . . .  .  .    . .    . . .   . . .    . . . . .    14 
15  Other current liabilities (attach schedule)   . . .   . . .    . . . . .    15 
16  Loans from shareholders and other related persons  .    . .    . . . . .    16 
17  Other liabilities (attach schedule)  . . .    . . .   . . .    . . . . .    17 
18  Capital stock: 
a   Preferred stock  .    . . . .  .  .    . .    . . .   . . .    . . . . .    18a 
b   Common stock  .       . . . .  .  .    . .    . . .   . . .    . . . . .    18b 
19  Paid-in or capital surplus (attach reconciliation)  . . . .    . . . . .    19 
20  Retained earnings  .    . . .  .  .    . .    . . .   . . .    . . . . .    20 
21  Less cost of treasury stock  . .  .    . .    . . .   . . .    . . . . .    21  (                                ) (                                )

22  Total liabilities and shareholders’ equity  . . . .   . . .    . . . . .    22 
                                                                                                         Form 8621-A (12-2013)